Chronic Rhinosinusitis: Outcomes of Medical and Surgical Treatment

Quality of Life Following Initial Medical Treatment

Medical management is the foundation of treatment for CRS. Numerous topical and systemic treatments are employed in the management of CRS, with each leading to different outcomes. This section describes outcomes of medical management for patients with primary, nonrefractory CRS who have not yet had a thorough trial of medical therapy and focuses on commonly used medications in the initial treatment of CRS. Such treatments include nasal saline irrigations, topical and oral corticosteroids, and oral antibiotics. Although there are numerous other agents that may be used, these medications are among the most frequently employed.

High-volume nasal saline irrigations improve disease-specific QoL via the SNOT-20, RSDI, and 31-item Rhinosinusitis Outcome Measurement (RSOM-31) as well as symptom scores and endoscopic scores; on the other hand, improvement in general health-related QoL via the 12-item and 36-item Short Forum Surveys (SF-12, SF-36) has not been as readily observed. Low-volume saline sprays as compared to high-volume irrigations have not yielded significant QoL improvement. Topical intranasal corticosteroids improve symptoms (congestion, rhinorrhea, hyposmia/anosmia, and facial pain/pressure) in patients with CRS without nasal polyposis (CRSsNP); in patients with CRS with nasal polyposis (CRSwNP), they reduce polyp size and mitigate polyp recurrence. Short 2- to 3-week courses of oral corticosteroids temporarily improve symptoms, decrease polyp size, and improve RSOM-31 in the CRSwNP population; this benefit likely lasts for approximately 3 to 6 months before a worsening occurs. Use of these agents must be balanced with the risks associated with the systemic administration of corticosteroids. Oral antibiotics, though commonly prescribed for CRS, may not be particularly useful for patient outcomes. Macrolide antibiotics improve certain symptoms and endoscopy scores and may improve SNOT-20 scores in patients with CRSsNP, whereas doxycycline has been shown to reduce polyp size in patients with CRSwNP.

Overall, medical therapy for primary, nonrefractory CRS leads to improvement for some percentage of patients. The proportion of patients with CRS whose disease is controllable via these means has not been well established, and it is evident that a significant percentage of patients continue to experience symptoms despite this primary medical management. Although there are many studies evaluating the outcomes of individual medication classes in managing CRS, few have evaluated the ideal, multi-agent regimen that would constitute the ideal appropriate medical therapy (AMT), previously referred to as maximal medical therapy. Consensus recommendations for which medications should be utilized in a trial of AMT have only recently been proposed. The current, broadly accepted treatment paradigm for CRS is to initially manage patients with medical therapy in an attempt to control the disease and its symptoms. Patients with CRS whose disease cannot be managed with AMT are said to have refractory disease and are considered candidates for ESS or continued AMT (CAMT). Given the prioritization of PROMs, the success of AMT can be defined as a symptomatic improvement and not exclusively by endoscopic or radiographic changes, such that ongoing symptoms are not sufficiently bothersome to warrant surgery. However, it should be noted that objective evidence of disease following AMT has been associated with clinical relapse, and some researchers have suggested that symptomatic responses to medical therapy must be balanced with control of long-term inflammation. Success rates for AMT with regard to preventing progression to surgery have been reported at 30% to 90%.

Quality of Life Following Medical Treatment for Refractory Disease

The choice of medical or surgical therapy for patients with refractory CRS is a complex and individualized decision that involves a thorough assessment of the anticipated efficacy of each treatment as well as the associated risks. This choice involves shared decision making, a process in which clinicians and patients work together to make decisions and select management based on clinical evidence as well as patient preferences and values. It is important to acknowledge that patients with refractory CRS who select ongoing medical therapy are typically affected differently by their disease than those who select surgical therapy, the former having a milder symptom burden on average. In general, patients with refractory CRS who elect CAMT have been shown to have less severe disease-specific QoL impairment as measured by CSS total score, CSS symptom score, and SNOT-22 total score and better baseline health utility compared with patients who elect ESS.

Reports on the efficacy of CAMT for refractory CRS demonstrate that this treatment modality results in either a mild increase in QoL or a stabilization of decreased QoL. In a prospective study, patients with refractory CRS who elected CAMT experienced some improvements in disease-specific QoL as measured by RSDI total score and subscores as well as CSS total score and symptom score. CAMT, however, did not result in decreased utilization of oral corticosteroids or antibiotics or fewer missed days of work/school for patients. A prospective follow-up study separated these patients who initially elected CAMT into groups based on ongoing treatment modality and elucidated that there are subgroups of patients for whom CAMT is more or less effective. One subset, approximately two-thirds of patients, experienced an improvement in QoL with CAMT as measured by RSDI scores and CSS symptom and total score; they elected to continued medical management. The remaining one-third did not experience QoL improvement with CAMT and crossed over to select surgical treatment.

Additional evidence suggests that CAMT maintains QoL yet does not frequently provide clinically meaningful improvement. A prospective study of patients with refractory CRS who elected CAMT found that the majority of these patients did not experience an improvement in mean SNOT-22 score of at least one MCID; only one in four patients achieved an improvement of at least one MCID, whereas one in five experienced a worsening of at least one MCID. In addition to CRS-specific QoL, patients with refractory CRS have impaired sleep relative to non-CRS controls and commonly have comorbid depression. CAMT results in improvements in depression but does not improve sleep deficits.

Although CAMT results in mild improvement or stability of QoL in certain patients, QoL worsens in patients awaiting ESS despite ongoing CAMT. A prospective Canadian study of patients with refractory CRS who elected ESS followed a refractory CRS cohort with more severely impaired baseline QoL score for an average of 7.1 months while these patients were awaiting surgery. Patients continued medical therapy during this waiting period, which consisted of increased usage of budesonide and saline irrigations to optimize medical management with a compensatory decrease in traditional nasal corticosteroid sprays and no change in utilization of systemic corticosteroids, antibiotics, antihistamines, or antileukotrienes. While awaiting surgery, patients experienced mean worsening of SNOT-22 scores by 8.5 points, thus approaching one MCID, mean worsening of LK scores, and a mean increase of 3.6 work days missed.

In summary, among patients with refractory CRS, current evidence has demonstrated that patients are more likely to select CAMT as a treatment modality if they have less severe QoL impairment from their disease. This contrasts with patients who are more severely affected by CRS and have been more likely to select ESS, as discussed in the following section. Relatively few high-quality studies have been performed that evaluate the efficacy of CAMT in the refractory CRS population. In these less severely affected patients who select CAMT, ongoing medical therapy either maintained a stable level of decreased QoL or improved QoL mildly.